Worldwide, every year, an estimated 127,000 women die as a result of blood loss following labour and delivery. It is the world’s leading cause of maternal mortality, accounting for a quarter of all maternal deaths. In total there are 14 million cases of haemorrhage occurring every year in association with pregnancy and childbirth, the majority of which are because failure of the uterus to contract properly after delivery of the placenta results in heavy bleeding or postpartum haemorrhage. In Study Session 6 you learned about the management of the third stage of labour, which begins with delivery of the baby and ends with delivery of the placenta and fetal membranes.
In this study session, you will learn about postpartum haemorrhage (PPH) and its management. PPH is one of the most alarming and serious emergencies in childbirth and your rapid actions can save many lives. Do not forget that antepartum haemorrhage (excessive bleeding before labour begins) can also threaten the life of the mother and fetus. You learned about early and late pregnancy bleeding in Study Sessions 20 and 21 of the Antenatal Care Module.
Can you recall the two most common causes of late pregnancy bleeding?
They are: placenta previa, when the placenta is close to or covering the cervix and it tears away as the cervix begins to efface and dilate as labour begins; and placental abruption, when the placenta is situated normally in the top two-thirds of the uterus, but it detaches before the birth of the baby.
When you have studied this session you should be able to:
11.1 Define and use correctly all of the key words printed in bold. (SAQ 11.1)
11.2 Describe the causes and risk factors for atonic and traumatic postpartum haemorrhage. (SAQ 11.2)
11.3 Describe interventions that can help to prevent postpartum haemorrhage, including actions during pregnancy and labour stages two and three. (SAQ 11.3)
11.4 Explain how you would provide emergency management for women who develop postpartum haemorrhage. (SAQ 11.3)
Postpartum haemorrhage (or PPH) is defined as excessive bleeding from the reproductive tract at any time following the baby’s birth and up to six weeks after delivery. Some 70–90% of PPH cases occur within the first 24 hours after delivery and are due to failure of the uterus to contract properly after the placenta detaches. Firm uterine contraction is necessary to close off the torn blood vessels in the placental bed.
Risk factors are existing underlying conditions which make a condition more likely to happen or more dangerous.
PPH is an unpredictable and rapid cause of maternal death. It is unpredictable in that two-thirds of women who develop PPH have none of the known risk factors (doctors refer to an adverse condition as idiopathic if there is no known reason why it occurred). In other cases, a woman with PPH does have one or more of the known risk factors (we review them later in this study session), or the PPH is due to mismanagement of the third stage of labour by the healthcare provider.
You learned how to measure blood pressure and pulse in Session 9 of the Antenatal Care Module; the causes and management of haemorrhagic shock were covered in Sessions 20–22 of that Module.
In normal births, the mother usually loses a small amount of blood (about 150 ml or a cupful) as the baby is born and after delivery of the placenta. When the amount exceeds 300 ml (2 cupfuls) it is considered as heavy bleeding (Figure 11.1). Excessive bleeding is often defined as more than 500 ml of blood loss. However, for severely anaemic women, blood loss of even 200–250 ml can be fatal. For that reason, a better definition of postpartum haemorrhage might be ‘any amount of bleeding that causes deterioration in the woman’s condition and signs of haemorrhagic shock’, i.e. low blood pressure, fast pulse, pallor, weakness or confusion).
Postpartum haemorrhage can be classified based upon the timing of the bleeding following delivery of the baby and the cause of the bleeding.
Classifications based on the timing of bleeding are:
Classifications based on the cause of the bleeding are termed either atonic or traumatic PPH. We will discuss each of these and their management in the next two sections.
The word ‘atonic’ means ‘loss of muscular tone or strength to contract’. Atonic postpartum haemorrhage is characterised by excessive bleeding when the uterus is not well contracted after the delivery, and is soft, distended and lacking muscular tone.
More precisely, in atonic PPH, the myometrium (the muscle layer in the wall of the uterus) fails to contract and compress the maternal blood vessels that tear as the placenta pulls away from the wall of the uterus. Most bleeding after birth comes from the place where the placenta was previously attached. If the myometrium fails to constrict strongly, it cannot compress the blood vessels to control the bleeding.
Any condition that interferes with uterine contraction, such as a retained placenta, remnants of placental tissue, or retained amniotic membranes or blood clots, increases the risk of excessive bleeding. If the placenta has separated but is still, even partially, in the uterus, it can prevent the uterus from contracting. Even a small piece of placenta or a blood clot left inside the uterus can keep it in the atonic condition. When the uterus is not contracted, the mother’s blood vessels continue to pump blood out and the woman will quickly lose blood.
The real problem with atonic PPH is that you cannot predict who will bleed excessively after the birth, and this is because two-thirds of women who develop atonic PPH have no known risk factors. This is why it is important to remember that all women must be considered at risk and prevention of PPH must be a part of every birth. The most important known risk factors are summarised below.
Note that while you cannot prevent an atonic uterus from occurring (nor can you always predict it), knowing the factors that make it more likely will help you to be alert to these possible signs of atonic PPH:
Anaemia (lack of red blood cells due to low haemoglobin) puts the mother at greater risk of postpartum haemorrhage, because her blood does not clot as easily as in a non-anaemic person. Blood loss is also more serious in someone with anaemia. (You learned about the diagnosis and management of anaemia during pregnancy in Study Session 18 of the Antenatal Care Module.)
Study Session 6 described how active management of delivery of the placenta should be conducted and what actions should be avoided.
What is the name given to the correct method of actively assisting delivery of the placenta?
It is called controlled cord traction.
What incorrect actions by the birth attendant during the third stage could result in postpartum haemorrhage?
Trying to deliver the placenta before it separates; pushing down on the fundus of the uterus while pulling on the umbilical cord; not waiting for a contraction before applying controlled cord traction and/or not applying counter-pressure to the mother’s abdomen. (Read Study Session 6 again if you are unsure of the steps in controlled cord traction.)
In traumatic postpartum haemorrhage, excessive bleeding occurs as a result of trauma (injury) to the reproductive tract following delivery of the baby. Trauma can occur to the cervix, vagina, perineum or anus. It could also be from a ruptured uterus (see Study Session 10). Signs of traumatic postpartum haemorrhage are when there is bleeding from the vagina but the uterus is well contracted (hard).
Trauma to the reproductive tract is preventable through skilled and gentle management during delivery, and referring the mother in good time if the labour is prolonged, or if the fetus is in an abnormal presentation or malposition (Study Session 8).
In this section we briefly review the actions you can take at different stages to reduce the risk of postpartum haemorrhage occurring – beginning with a pregnant woman before labour starts.
You should arrange for women with known risk factors (as described above for atonic PPH) to give birth in a health facility, where the risk of PPH can be more easily managed and urgent action taken if it occurs. In some cases (e.g. of placenta previa, malpresentation or twins), the baby may have to be delivered by caesarean surgery. There are many reasons why women may not want to go to a health facility, and it is important that you explain clearly and sensitively to mothers who are at increased risk why it is not safe for them to give birth at home. If they refuse, make sure that an emergency referral plan is in place and that potential blood donors are ready in case the woman needs a blood transfusion.
The high risk of PPH associated with anaemia is one reason why you should screen routinely for anaemia at every antenatal (and postnatal) visit, and take action to prevent it.
What should you do to prevent anaemia in the pregnant women in your care?
Counsel them on good nutrition with a focus on available iron-rich and folate-rich foods (e.g. dark green leafy vegetables, whole grains, red meats, eggs) and provide iron/folate supplements.
You learned how to do this in the Antenatal Care Module as part of focused antenatal care (Study Session 13), nutrition in pregnancy (Study Session 14), and the prevention and treatment of anaemia (Study Session 18).
What actions should you take to prevent anaemia caused by malaria and hookworm?
Encourage the use of insecticide-treated bed nets as protection against being bitten by the mosquitoes that transmit the malaria parasite. Provide treatment (mebendazole) after the first trimester of pregnancy in areas of high hookworm prevalence.
Malaria and hookworm are covered in detail in the Communicable Diseases Module.
For women with no known risk factors, you can reduce the risk of PPH by correct and careful management of the third stage of labour, as described in Study Session 6. In summary, the main points to remember are as follows:
You learned the principles of urinary catheterisation in Study Session 22 of the Antenatal Care Module and your practical skills training.
There are interventions you can make before, during and after labour which may help to reduce the risk of PPH. Quickly see how many of these you can list.
To check how well you answered, re-read Sections 11.4.1, 11.4.2 and 11.4.3 of this study session.
However, remember that even if you make all the interventions possible, postpartum haemorrhage can still occur unpredictably after any delivery and you should always be prepared to take emergency action, as described next.
If the mother begins to bleed excessively after the delivery, you must take action quickly to transport her to the nearest health facility. Postpartum haemorrhage can kill her and many healthcare providers underestimate how much blood a woman loses. If you face such a problem your first action should be to shout for help so the woman’s family or neighbours come to help you take her to the nearest health facility (Figure 11.4).
If the mother is bleeding heavily, while you are waiting for the emergency transport, give her a second dose of oxytocin 10 IU by intramuscular injection, or a second dose of misoprostol 400 µg rectally (by pushing the tablets gently into the rectum through the woman's anus), or by putting the tablets under her tongue where they can slowly dissolve. Do not give additional misoprostol if oxytocin was the drug used originally.
Do not exceed 1,000 µg of misoprostol! If you gave 600 µg orally straight after the baby was born, the second dose should be no more than 400 µg rectally.
If you have been trained to do so, begin pre-referral infusion of intravenous (IV) fluids to prevent and treat shock. Infuse Normal Saline 9% or Ringer’s Lactate solution, set with the fastest possible flow rate. Ensure that the bag of IV solution is held higher than the woman’s head all the time, including when she is being transported to the nearest health facility.
You learned the principles of IV fluid infusion in Study Session 22 of the Antenatal Care Module and your practical skills training.
If bleeding is very heavy and rubbing the uterus does not stop the bleeding, try two-handed pressure on the uterus (see Figure 11.5). Scoop up the uterus, fold it forward, and squeeze it hard (you will be shown how to do this in your practical skills training). Cup one hand over the top of the uterus. Put your other hand above the pubic bone and push the uterus towards your cupped hand. You should be squeezing the uterus between your two hands.
If you have been trained to do so, you can apply two-handed uterine compression by inserting one gloved hand inside the vagina and clenching your hand behind the cervix, while the other hand is pressing on the abdomen to compress the uterus.
As soon as the bleeding slows down and the uterus feels firm, slowly stop the two-hand pressure. If bleeding continues, refer the woman to the nearest health centre facility. Try to keep two-handed pressure on the uterus while you are transporting the mother. Do not leave the baby behind – have someone carry it. Make sure you take possible blood donors from her relatives with you as the woman may need a blood transfusion.
Try to slow the bleeding from an injury (e.g. a tear in the perineum or vagina) by applying pressure over the source of the haemorrhage. Roll up 10 to 15 pieces of sterile gauze or a small, sterile cloth into a thick pad and push it firmly against the bleeding part of the tear. Hold it there for 10 minutes. Carefully remove the gauze and check for bleeding. If the tear is still bleeding, press the gauze against the source of the haemorrhage again and take the woman to the nearest health facility. Do not stop pressing on the tear until you get to there. If the woman has a long or deep tear, even if it is not bleeding much, take her to a health facility where it can be repaired.
Finally, as we come to the end of this Module on Labour and Delivery Care, Table 11.1 summarises some key points to remember during emergency referral for postpartum haemorrhage, or any of the other life-threatening emergencies described in earlier study sessions. In the next Module, the continuum of care moves forward to the conduct of Postnatal Care.
|Aim to maintain:||Actions|
Contraction of the uterus
|Apply gentle uterine massage, or two-handed compression of the uterus, and maintain this during referral|
|If the woman cannot urinate, insert a self-retaining catheter to drain the bladder and leave it in place during referral|
Adequate blood volume
|If the woman is haemorrhaging or in shock, administer intravenous fluids and maintain the infusion during referral|
|Check colour, pulse, blood pressure, temperature, blood loss, level of consciousness|
|Cover the woman with blankets|
|The woman should lie flat, but with her legs raised above the height of her head to help maintain her blood pressure|
|Give the woman your emotional support and reassurance; keep her as calm as possible|
Accurate records and referral note
|Write down all your findings and the interventions you are making on the referral note, with the woman’s history and identification details|
What are the two most important points to remember about PPH?
You should remember that:
In Study Session 11, you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
You are drafting the information that you want to send with the referral notice for a mother with PPH and you write it out as below. A young trainee colleague asks you to explain what you have written. How would you explain your referral note, including all the terms in bold, so that your colleague can understand?
‘I am referring Mebrihit. She is a high parity mother with excessive bleeding and is considered to be experiencing primary postpartum haemorrhage. I was careful to avoid trauma when assisting her delivery. Palpation indicates atonic postpartum haemorrhage which I suspect is due to failure of the myometrium.’
Here is how you could have explained to your trainee colleague what you had written in your referral note:
‘I am referring Mebrihit. She has had more than 5 pregnancies (high parity) and developed bleeding in excess of 500 ml of blood (excessive bleeding) within 24 hours of delivery (primary postpartum haemorrhage). I was very careful to avoid any injury (trauma) during the delivery. Feeling her abdomen (palpation) indicates that her uterus is soft and has not contracted properly after delivery (atonic postpartum haemorrhage). I suspect this is because the muscular wall of her uterus (myometrium) is failing to contract and close the blood vessels where the placenta pulled away from the uterus’.
You are assessing a pregnant woman in your care for potential risk of PPH.
Here are some of the questions to ask and things to do. We expect you may have thought of even more.
Gelila delivered a baby 40 minutes ago. You gave her 600 µg of misoprostol orally immediately after the birth, but the placenta has not come out yet. She has emptied her bladder. After 10 minutes the placenta comes out and you check that it is intact, but Gelila starts bleeding heavily. What do you do?
Here is what you should do: